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psnet.ahrq.gov/issue/missed-diagnosis-cancer-primary-care-insights-malpractice-claims-data
March 15, 2017 - Contributing factors included failure or delay in test ordering or consultation .
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psnet.ahrq.gov/issue/6-pack-programme-decrease-fall-injuries-acute-hospitals-cluster-randomised-controlled-trial
December 21, 2014 - The bundle included assessing patients' risk for falling along with several widely used tactics to prevent
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psnet.ahrq.gov/issue/exploring-situational-awareness-diagnostic-errors-primary-care
September 20, 2011 - framework to analyze such errors provided deeper insight into the provider–work system interaction, which included
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psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
September 23, 2024 - short online survey accessed via QR code post-RIC Other clinical pathways developed alongside the RIC included … fluid management , and decompensation during bedside tracheostomy . 1 The evaluation of the innovation included … short online survey accessed via QR code post-RIC Other clinical pathways developed alongside the RIC included
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psnet.ahrq.gov/node/73086/psn-pdf
January 01, 2022 - Fear of negative
consequences was the most common barrier; other barriers included inadequate reporting
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psnet.ahrq.gov/node/73495/psn-pdf
July 14, 2021 - Thematic analyses suggest that the most commonly used implementation strategies
included restructuring
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psnet.ahrq.gov/node/46123/psn-pdf
January 01, 2020 - Handoff strategies differed
widely among the included studies.
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psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery
September 15, 2024 - However, this estimate only included procedures performed in the operating room; if procedures performed … in other settings (for example, ambulatory surgery or interventional radiology) are included, the rate
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psnet.ahrq.gov/issue/national-implementation-project-prevent-catheter-associated-urinary-tract-infection-nursing
April 05, 2017 - This sociotechnical approach included checklists , care team education, leadership engagement , communication
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psnet.ahrq.gov/issue/comparing-outcomes-reporting-and-trigger-tool-methods-capture-adverse-events-emergency
May 04, 2017 - The system included two event reporting methods and five trigger tools.
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psnet.ahrq.gov/issue/frequency-diagnostic-errors-outpatient-care-estimations-three-large-observational-studies
April 09, 2013 - studies used a trigger approach to review unusual patterns of return visits in primary care and one study included
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psnet.ahrq.gov/issue/cost-implications-reduced-work-hours-and-workloads-resident-physicians
August 05, 2015 - These recommendations included eliminating extended duration shifts or scheduling nap times during
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psnet.ahrq.gov/issue/outcomes-daytime-procedures-performed-attending-surgeons-after-night-work
December 18, 2014 - This study included many institutions, physicians, and procedure types, suggesting that short-term sleep
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psnet.ahrq.gov/issue/quasi-experimental-evaluation-effectiveness-large-scale-readmission-reduction-program
January 07, 2015 - targeting only high-risk patients and providing them with a personalized transitional care plan that included
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psnet.ahrq.gov/issue/incidence-and-preventability-adverse-drug-events-among-older-persons-ambulatory-setting
March 11, 2011 - enrollees in a single multispecialty group practice capturing events through a number of strategies that included
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psnet.ahrq.gov/issue/transforming-medication-regimen-review-process-using-telemedicine-prevent-adverse-events
November 11, 2015 - The program included telemedicine-based medication reconciliation at admission and medication regimen
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psnet.ahrq.gov/issue/medicines-reconciliation-using-shared-electronic-health-care-record
March 04, 2015 - Problems included outdated or incomplete medication information, incorrect information provided by patients
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psnet.ahrq.gov/issue/bridging-leadership-roles-quality-and-patient-safety-experience-6-us-academic-medical-centers
September 04, 2016 - Key responsibilities included clinical oversight, faculty development , and educational innovation.
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psnet.ahrq.gov/issue/preventable-proportion-healthcare-associated-infections-2005-2016-systematic-review-and-meta
April 26, 2017 - From the 144 studies ultimately included in the analysis, they found that implementation of evidence-based
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psnet.ahrq.gov/issue/how-not-waste-crisis-qualitative-study-problem-definition-and-its-consequences-three
April 21, 2015 - This qualitative study included interviews, extensive ethnographic observation, and review of documents